The Difference Between a ‘Public Option’ and ‘Medicare for All’? Let’s Define Our Terms

Various proposals are floating around, each of which would change the health care system in distinct ways. Some, like one from Senator Bernie Sanders, would do away with all private health insurance. Some would make small expansions in existing public programs. Some would try to cover all Americans through a mix of different insurance types.

It can be mystifying when people call all of these ideas “Medicare for all,” as some in the debate have been doing.

.. Private plans handle Medicare drug coverage, and you can choose among options. You pay premiums each year, and you pay deductibles and co-payments when you use medical services.

Because the program’s out-of-pocket spending has no limits, most Medicare beneficiaries also buy private supplemental insurance to limit those costs. That insurance doesn’t cover medical services outside the Medicare system, but it helps pay the patient’s share of the bill when a person goes to the doctor or hospital.

.. Mr. Sanders, who prominently featured such a plan in his 2016 presidential platform and just announced he has joined the 2020 race, uses this term a lot. His plan would both expand traditional Medicare to cover all Americans, and change the structure of the program, to cover more services and eliminate most deductibles and co-payments. So the Medicare everyone would be getting would differ in crucial ways from the Medicare older people get now.

Progressive Capitalism Is Not an Oxymoron

We can save our broken economic system from itself.

Despite the lowest unemployment rates since the late 1960s, the American economy is failing its citizens. Some 90 percent have seen their incomes stagnate or decline in the past 30 years. This is not surprising, given that the United States has the highest level of inequality among the advanced countries and one of the lowest levels of opportunity — with the fortunes of young Americans more dependent on the income and education of their parents than elsewhere.

But things don’t have to be that way. There is an alternative: progressive capitalism. Progressive capitalism is not an oxymoron; we can indeed channel the power of the market to serve society.

In the 1980s, Ronald Reagan’s regulatory “reforms,” which reduced the ability of government to curb the excesses of the market, were sold as great energizers of the economy. But just the opposite happened: Growth slowed, and weirder still, this happened in the innovation capital of the world.

The sugar rush produced by President Trump’s largess to corporations in the 2017 tax law didn’t deal with any of these long-run problems, and is already fading. Growth is expected to be a little under 2 percent next year.

This is where we’ve descended to, but not where we have to stay. A progressive capitalism based on an understanding of what gives rise to growth and societal well-being gives us a way out of this quagmire and a way up for our living standards.

Standards of living began to improve in the late 18th century for two reasons:

  1. the development of science (we learned how to learn about nature and used that knowledge to increase productivity and longevity) and
  2. developments in social organization (as a society, we learned how to work together, through institutions like the rule of law, and democracies with checks and balances).

Key to both were systems of assessing and verifying the truth. The real and long-lasting danger of the Trump presidency is the risk it poses to these pillars of our economy and society, its attack on the very idea of knowledge and expertise, and its hostility to institutions that help us discover and assess the truth.

There is a broader social compact that allows a society to work and prosper together, and that, too, has been fraying. America created the first truly middle-class society; now, a middle-class life is increasingly out of reach for its citizens.

America arrived at this sorry state of affairs because we forgot that the true source of the wealth of a nation is the creativity and innovation of its people. One can get rich either by adding to the nation’s economic pie or by grabbing a larger share of the pie by exploiting others — abusing, for instance, market power or informational advantages. We confused the hard work of wealth creation with wealth-grabbing (or, as economists call it, rent-seeking), and too many of our talented young people followed the siren call of getting rich quickly.

Beginning with the Reagan era, economic policy played a key role in this dystopia: Just as forces of globalization and technological change were contributing to growing inequality, we adopted policies that worsened societal inequities. Even as economic theories like information economics (dealing with the ever-present situation where information is imperfect), behavioral economics and game theory arose to explain why markets on their own are often not efficient, fair, stable or seemingly rational, we relied more on markets and scaled back social protections.

We are now in a vicious cycle: Greater economic inequality is leading, in our money-driven political system, to more political inequality, with weaker rules and deregulation causing still more economic inequality.

If we don’t change course matters will likely grow worse, as machines (artificial intelligence and robots) replace an increasing fraction of routine labor, including many of the jobs of the several million Americans making their living by driving.

The prescription follows from the diagnosis: It begins by recognizing the vital role that the state plays in making markets serve society. We need regulations that ensure strong competition without abusive exploitation, realigning the relationship between corporations and the workers they employ and the customers they are supposed to serve. We must be as resolute in combating market power as the corporate sector is in increasing it.

If we had curbed exploitation in all of its forms and encouraged wealth creation, we would have had a more dynamic economy with less inequality. We might have curbed the opioid crisis and avoided the 2008 financial crisis. If we had done more to blunt the power of oligopolies and strengthen the power of workers, and if we had held our banks accountable, the sense of powerlessness might not be so pervasive and Americans might have greater trust in our institutions.

The neoliberal fantasy that unfettered markets will deliver prosperity to everyone should be put to rest. It is as fatally flawed as the notion after the fall of the Iron Curtain that we were seeing “the end of history” and that we would all soon be liberal democracies with capitalist economies.

Most important, our exploitive capitalism has shaped who we are as individuals and as a society. The rampant dishonesty we’ve seen from Wells Fargo and Volkswagen or from members of the Sackler family as they promoted drugs they knew were addictive — this is what is to be expected in a society that lauds the pursuit of profits as leading, to quote Adam Smith, “as if by an invisible hand,” to the well-being of society, with no regard to whether those profits derive from exploitation or wealth creation.

 

‘Medicare for All’ Isn’t Sounding So Crazy Anymore

To be able to deliver on its promises, single payer would not only require trillions in new revenue through higher taxes, but also huge cost savings from slashing payments to drug companies, doctors and hospitals. “There are a million and one complexities” to single payer that no one has really dealt with, said Dean Bake

.. Senator Sanders went out of his way to list all the tax hikes he’d use to pay for his 2016 proposal, including an across-the-board 2.2 percent income tax. But two prominent policy analysts said the plan would cost about twice as much as the senator claimed.

.. But many advanced, industrialized democracies with universal coverage don’t have a pure single-payer system. France, for instance, has health care for all that is largely state-financed, but most people also buy private supplemental coverage.

.. Mr. Baker believes the top priority is a credible transition plan. “If you just take everyone with employer-provided insurance and put all of them on a public plan, you’re going to freak people out,” he said. He’s interested in reviving the public option — a government-run plan that would compete with private insurance on the exchanges — as well as opening up Medicare or Medicaid to those who want to buy in.

.. Democrats risk making the same mistake on health care as Republicans: big promises without a plan to follow through.

The Best Way to Save Obamacare

As someone involved in the debate over the Affordable Care Act from the start, I don’t find these unhappy events all that surprising. From the outset, I’ve argued that without a public option — a Medicare-like plan that would be available to all Americans buying health insurance — insurance competition would dwindle and premiums would skyrocket. Now that they have, it’s time to do now what we should have done then: take the simplest route to a more stable and affordable health care system.

.. We’re already heading toward single payer in sections of the nation — only it’s a private plan doing the paying. Next year, five states will have only one insurer in their exchanges, the online marketplaces set up to allow uninsured Americans to buy subsidized coverage. Nine more states will have just two insurers.

.. The diminishing number of choices doesn’t just hurt consumers; it also makes it harder for regulators to use antitrust tools to push back against this consolidation. Who wants to be the official accused of causing an insurer to leave the exchanges? It’s a perverse equation: As the number of insurers goes down, the leverage they have over regulators goes up.

.. In polls conducted in 2009 and 2010, substantial majorities of Americans said they would feel better about being required to have coverage if they had the choice of a public plan.

.. In polls conducted in 2009 and 2010, substantial majorities of Americans said they would feel better about being required to have coverage if they had the choice of a public plan.